South African Medical Journal (SAMJ)
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A randomised trial comparing preoperative administration of single-dose kefazolin to kefazolin plus metronidazole as prophylactic antibiotics at caesarean section
Get PDFBackground. Caesarean section is a life-saving procedure which is associated with high rates of maternal and neonatal complications. It has been estimated that globally, 29.7 million births occur by caesarean section annually. The risk of postpartum infection is estimated to be five to ten times higher compared with normal vaginal delivery. Pregnancy-related sepsis was listed as a top-six cause of maternal mortality in the South African Saving Mothers report between 2017 and 2019. Multiple trials have been conducted in an attempt to optimise administration of prophylactic antibiotics in an effort to reduce postpartum infection and maternal sepsis, and current practice guidelines suggest that there is sufficient evidence that extended-spectrum antibiotics, in combination with kefazolin, result in reduction of postpartum infections.
Objectives. To investigate the effect of perioperative administration of kefazolin alone compared with kefazolin plus metronidazole on postpartum infection in women undergoing caesarean section at Kalafong Provincial Tertiary Hospital, Pretoria, South Africa.
Method. All patients undergoing emergency or elective caesarean section were randomised and then sequentially numbered in opaque sealed envelopes, which were placed in the caesarean section operating theatre. The intervention group received kefazolin and a sealed envelope with metronidazole. The control group received kefazolin and a sealed envelope with normal saline.
Results. A total of 57/1 010 patients (5.64%) had surgical site infections, of which 27 (5.33%) were in the control group, and 30 (5.96%) were in the intervention group (p=0.66). Two patients in each arm (0.40% in the intervention arm and 0.39% in the control arm) underwent laparotomy procedures, while three women (0.60%) in the intervention arm and four women (0.79%) in the control arm underwent hysterectomy procedures. There were no statistically significant differences in all the measured secondary outcomes between the two groups.
Conclusion. The overall sepsis rate in this study was 5.64%. Postpartum infection is multifactorial and there are multiple factors that can be addressed in strengthening the sepsis care bundle. We do not recommend the addition of metronidazole to kefazolin as prophylaxis at caesarean section
Post-colonoscopy colorectal cancers in privately insured patients in South Africa
Get PDFBackground. Post-colonoscopy colorectal cancers (PCCRCs) are colorectal cancers (CRCs) that are diagnosed within 3 - 5 years of a colonoscopy where a cancer was not detected. Colonoscopy is the current gold standard for the diagnosis of colorectal cancer. The rate of PCCRC is an indicator of the quality of colonoscopy, because the aim of a high-quality colonoscopy is to detect CRCs and advanced adenomas.
Objective. To calculate the rate of PCCRC in a privately insured population in South Africa (SA).Methods. Data were retrospectively obtained from the largest private health insurance company in SA. Patients diagnosed with CRC from the period of 1 January 2013 to 31 December 2019 were included. Patients who were members of the fund for <5 years prior to diagnosis were excluded. Patients with conditions predisposing to CRC were excluded from the study. Patients with CRC who had undergone colonoscopy 6 - 60 months prior to the diagnosis of CRC were defined as PCCRC. Patients diagnosed with CRC were identified by ICD-10 codes and from the oncology registry. Colonoscopies were identified by procedure codes.
Results. A diagnosis of CRC was made in 19 538 patients in the 7-year period. Following exclusions, 4 765 patients were included in this study for analysis. PCCRC was identified in 415 patients (8.72%) between 6 and 60 months, of whom 315 were identified between 6 and 36 months (6.61%). The median (interquartile range (IQR)) age in the overall study group presenting with CRC was 64 (53 - 73) years, with that of the PCCRC group (n=415) being higher at a median (IQR) age of 67(53 - 72) years when compared with the non-PCCRC group (n=4 350) of 64 (53 - 72) years (p=0.0002). Overall, 21.3% of CRC patients were aged ≤50 years, and 51.3% were male. The percentages of patients aged ≤50 years in the PCCRC v. non-PCCRC groups were 17.1% (n=71/415) and 21.7% (n=945/4 350), respectively (p=0.03). The gender ratio did not differ in the PCCRC group v. the non-PCCRC group. Rectal cancers were more likely to be present in the PCCRC group at 32.8% (n=136/415) v. the non-PCCRC group at 24% (n=1 043/4 350) (p<0.001). In the PCCRC subset, 73.8% of colonoscopies were performed by surgeons, 13.4% by gastroenterologists and 12.8% by physicians and general practioners/others. The PCCRC rate was 14.4% for gastroenterologists and 7.9% for surgeons.
Conclusion. This study is the first study from SA to analyse PCCRC. The overall PCCRC rate was 6.61%, in line with published series
Trends and distribution patterns of infant mortality and maternal HIV positivity in South Africa: A decade review (2007 - 2016)
Get PDFBackground. The infant mortality rate (IMR) (24 per 1 000 live births) remains high in South Africa (SA), well above the recommended sustainable development goal (SDG) 3 of 12 deaths per 1 000 live births. High infant mortality is a poor indicator of the health of a population and will hamper attainment of the SDGs.
Objectives. To investigate the trends and distribution patterns of IMR between 2007 and 2016 and its association with HIV-positive pregnant mothers in SA.
Methods. This study used a cross-sectional study design by analysing secondary data on infant mortality from the 2007 and 2016 Statistics South Africa Community Surveys (CSs), as well as data from the 2007 National Antenatal Sentinel HIV and Syphilis Prevalence Survey. (Antenatal HIV Sentinel Survey – ANCHSS). Line charts with descriptive statistics were used to detail trends in IMRs, and multiple logistic regression models were used to identify risk factors for infant mortality in the 2007 and 2016 CS datasets. Spearman’s rank-order correlation (rho) was used to correlate infant mortality with data from the 2007 ANCHSS. All analyses were performed with Stata version 16.0.
Results. A total sample of 87 805, comprising 43 922 males and 43 883 females, was included in the analysis. The results revealed a decline in IMR from 55 deaths per 1 000 live births in 2007 to 32 in 2016. Overall, there was a significant decrease in the mortality rate from 2007 to 2016. The infant mortality proportions by province showed KwaZulu-Natal Province having the highest IMR (17.5 deaths per 1 000 live births in 2007 and 6.3 in 2016). Males had a higher IMR (28 deaths per 1 000 live births in 2007 and 17.7 in 2016) compared with females at 26.7 deaths per 1 000 live births in 2007 and 13.8 in 2016. IMR data from the 2007 CS was correlated with the 2007 ANCHSS (28% HIV prevalence in 2007), using Spearman’s rank-order correlation, which showed a moderate correlation of 0.58 (p<0.001).
Conclusions. The study findings showed a reduction in the trends of infant mortality between 2007 and 2016 in SA; despite the reduction, health inequalities persist. There is a correlation evident between maternal HIV prevalence and IMR in SA. We recommend the use of disability-adjusted life expectancy in SA to measure population health and introduce robust data sets that can better inform policy
How far? Travel burdens for children admitted to hospitals in the Western Cape Province of South Africa
Get PDFBackground: The ability to access effective hospital care for children is a significant determinant of good health outcomes. The Western Cape is a large land area with a wide array of human settlements- both in urban and rural spaces. For many children in the Western Cape, after-hours access to healthcare becomes constrained when primary care clinics close and hospitals are either far away or difficult to get to. The cumulative travel burden of communities across this area is not known. The recently established data gathering capacity of the Provincial Health Data Centre of the Western Cape represents a new capacity to study this.
Objectives: This study intends to describe the cumulative travel burdens of children in communities throughout the Western Cape, and how they compare relative to one another, with a particular focus on the after-hours period in a week.
Methods: Over a period of 5 years from 2017-2021, all the admission details to every hospital in the Western Cape of children under 18 years of age were collected, with basic demographic and disease data including place of residence. The distance each child travelled to their first admission facility was calculated and represented within defined communities across the metro of Cape Town and the rural Western Cape.
Results: There were 574 220 admissions over the 5-year period, of which 360 783 were able to be used for travel analysis. The majority of admissions were for children under 5 years of age, were in the City of Cape Town and occurred after hours. Median travel distance was less for children outside of Cape Town, but the range of travelled distances was greater. Communities across the Western Cape, particularly rural communities, reflected significant variation in their cumulative travel burdens.
Conclusion: Using a large health dataset, this study demonstrates in a novel way for South Africa, the distances children travel to access admission facilities. A wide variation exists across all parts of the province, but particularly in rural areas. These findings could be further interrogated for people’s choices of facility and method of travel. Detailed service area modelling and extending primary care working hours are potential considerations for improving access at scale and at the local community level
Using machine learning models to plan HIV services: Emerging opportunities in design, implementation and evaluation
Get PDFHIV/AIDS remains one of the world’s most significant public health and economic challenges, with approximately 36 million people currently living with the disease. Considerable progress has been made to reduce the impact of HIV/AIDS in the past years through successful multiple HIV/AIDS prevention and treatment interventions. However, barriers such as lack of engagement, limited availability of early HIV-infection detection tools, high rates of HIV/sexually transmitted infections (STIs), barriers to access antiretroviral therapy, lack of innovative resource optimisation and distribution strategies, and poor prevention services for vulnerable populations still exist and substantially affect the attainment of the UNAIDS 95-95-95 targets. A rapid review was conducted from 24 October 2022 to 5 November 2022. Literature searches were conducted in different prominent and reputable electronic database repositories including PubMed, Google Scholar, Science Direct, Scopus, Web of Science, IEEE Xplore, and Springer. The study used various search keywords to search for relevant publications. From a list of collected publications, researchers used inclusion and exclusion criteria to screen and select relevant papers for inclusion in this review. This study unpacks emerging opportunities that can be explored by applying machine learning techniques to further knowledge and understanding about HIV service design, prediction, implementation, and evaluation. Therefore, there is a need to explore innovative and more effective analytic strategies including machine learning approaches to understand and improve HIV service design, planning, implementation, and evaluation to strengthen HIV/AIDS prevention, treatment, and awareness strategies
A decade-long overview of adverse events in a tertiary surgical service in South Africa
Get PDFBackground. Adverse events are common, and impact patients and healthcare systems negatively. Large international systems investigate adverse events at length, but South African data are lacking.
Objectives. To classify all adverse events that have occurred in our department over the last decade.
Methods. Ten years of data from a prospectively collated electronic medical record system were analysed for adverse events. All admitted patients were included. Duplicate entries and those that did not describe adverse events were excluded.
Results. The study period was from December 2012 to January 2023. There were 52 835 distinct admissions covering 321 385 inpatient days. After categorisation, a total of 14 537 adverse events were captured, giving an adverse event rate of 22%. Adverse events were categorised into four groups. Of the total, 8 027 events were clinical care related, 3 106 were pathology related, 2 662 were system related and 442 miscellaneous. A total of 300 were excluded. Clinical care-related adverse events comprised 57.3% of the total number. Of those, adverse events related to indwelling devices (32.4%), iatrogenic injuries (12.5%) and intravenous therapy administration (12.5%) contributed most. Pathology-related adverse events contributed 21.4% of the total, of which wound sepsis (29.5%), anastomotic leak (15.1%) and nosocomial pneumonia (14.4%) were the most common. There was a general downward trend in reported adverse events from 2016 to 2022.
Conclusion. Adverse events are common, and their aetiology is multifactorial. A sustained and multi-faceted approach is needed to address the challenge they pose
Community-led monitoring and the role of Ritshidze in improving the quality of primary healthcare in South Africa
Get PDFCommunity-led monitoring (CLM) of health services is a mechanism of community participation and accountability that is increasingly advocated across the globe. In South Africa (SA), a large-scale community-led monitoring initiative called Ritshidze (‘saving our lives’) was established in 2019. Steered by a coalition of civil society organisations representing people living with HIV, Ritshidze monitors just over 400 primary healthcare (PHC) facilities in 8 provinces on a quarterly basis. In this piece we describe the purposes and design features and the five-step approach to CLM of the Ritshidze model. We also highlight some of the positive changes achieved, and reflect on possible reasons for successes. In doing so, we aim to draw attention to this significant national initiative and its potential as a mechanism of social accountability in SA
